<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803698
Report Date: 12/31/2024
Date Signed: 12/31/2024 12:09:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241113121445
FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:ANTONETTE EDWARDSFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 28DATE:
12/31/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Serina BarredaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee does not ensure that the facility has an adequate supply of food for residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken and documents obtained and reviewed. In addition, unannounced inspections were made of the facility's food supply on three or more occasions. The following determinations are made: Complainant alleges that the facility does not have enough food for the residents in care; Unannounced site visits made to the facility on 11/13/24, 11/21/24, 12/5/24, 12/19/24 confirmed that sufficient fresh and non perishable food was observed on site that meets or exceeds the requirements of Title Twenty - Two; On 12/5 and 12/19/24, plated lunches were observed to meet regulations. Three Food Service staff deny that food service has been inadequate. Although the allegation that Licensee does not ensure that the facility has an adequate supply of food for residents in care may be true, based upon the observations and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the complaint is UNSUBSTANTIATED.

Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20241113121445

FACILITY NAME:VINEYARD AT FOUNTAINGROVE, THEFACILITY NUMBER:
496803698
ADMINISTRATOR:ANTONETTE EDWARDSFACILITY TYPE:
740
ADDRESS:200 FOUNTAINGROVE PKWYTELEPHONE:
(707) 544-4909
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:64CENSUS: 28DATE:
12/31/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Serina BarredaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator is not on the facility premises a sufficient number of hours
Facility is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation statements were taken and documents obtained and reviewed. In addition, four unannounced site visits were made to the facility. The following determinations are made: On or about 11/13/2024 Complainant alleged “no one is in charge” and that the Administrator has not been on site for two weeks; Site visits made to facility by CCL staff on 10/8, 12/5, 12/9, 12/19 noted the Administrator not present; Regional Vice President for Licensee has stated that the Administrator resigned as of 11/27 and a replacement will be on site 1/1/2024. Site visits made to facility over the past two months have documented facility in disrepair, including electrical problems in four apartments, lack of heat in one apartment, and a front door that does not lock. Based upon the statements and observations, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED.

Continued on next page

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20241113121445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE
FACILITY NUMBER: 496803698
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2025
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. * Based upon statements and observations, this requirement has not been met as evidenced by: The facility front door does not lock and one apartment lacks

1
2
3
4
5
6
7
Room heat has been corrected. Administration shall repair/replace front door lock and provide proof of correction to CCL by POC date in order to clear deficiency.
8
9
10
11
12
13
14
heat. This posses an immediate threat to the safety and health of residents. ***Civil Penalty in the amount of $250 is assessed for repeat violation within 12 months.
8
9
10
11
12
13
14


****This is an amended version of the
original document******
Type B
01/28/2025
Section Cited
CCR
87405
1
2
3
4
5
6
7
Administrator – Qualifications and Duties. The Administrator…shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility…*Based on statements and observations this requirement has not
1
2
3
4
5
6
7
Licensee to submit verification that a qualified Administrator has been designated and the days and hours the Administrator will be on site. Documentation to be submitted by POC date in order to clear the deficiency.
8
9
10
11
12
13
14
been met as evidenced by: Facility has been without an Administrator on site since 11/27/2024. This poses potential threat to the welfare of the residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20241113121445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINEYARD AT FOUNTAINGROVE, THE
FACILITY NUMBER: 496803698
VISIT DATE: 12/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Civil Penalty in the amount of $250.00 is assessed for repeat violation within 12 months.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4